The COVID-19 pandemic has posed unprecedented challenges to healthcare systems worldwide, with long-term care facilities being among the most critically affected (1). In long-term care settings, such an infection can rapidly spread by human-to-human transmission through direct contact or droplets (2, 3). As major long-term care facilities, long-term care hospitals (LTCHs) in Korea are hospitals that provide medical services to patients requiring extended care, primarily those with advanced age and a range of chronic underlying conditions (4, 5). These long-term care recipients are highly susceptible to the emerging infectious disease; 94.7% of LTCHs reported experiencing an outbreak in 2022 (6, 7). LTCHs across Korea have become focal points for COVID-19 outbreaks, reporting higher fatality rates (12%) than the domestic COVID-19 fatality rate (1.75%) during the first year since the initial case in Korea (8).

Given LTCHs' significant role in this era of aging, it is necessary to ensure that LTCHs respond appropriately when faced with various risks pertaining to calamities, such as infectious disease outbreaks (9). Managing the spread of the COVID-19 and changes within LTCHs entailed complex challenges that extended beyond standard healthcare practices, including testing all contacts and setting cohorts (10–12). According to an existing review (13) and the related literature (14), some actions taken to adapt to external/internal demand during the pandemic by resilient hospitals were beneficial based on preparedness, whereas measures implemented by other hospitals revealed vulnerabilities.

As such, the pandemic has highlighted the importance of building hospital resilience. Hospital resilience refers to a system's capacity to promptly and effectively withstand, absorb, adapt to, and recover from the impacts of hazards (15, 16). Several studies have found indicators to assess disaster-resilient hospitals, including leadership, in-hospital business continuity plan (BCP), and hospital management for disaster risk reduction (17–19). Importantly, pandemic plans as part of BCP focus on enabling critical hospital functions and strengthening preparedness for a disaster (20, 21). Healthcare facilities need to prepare for and respond to crises by considering these factors.

Concerning biological hazards, hospital resilience during COVID-19 has been explored in the literature, but it is still relatively limited, including the actual participation of frontline hospitals (16, 22). There is a need for further research to enhance hospital resilience in resource-constrained and fragile settings and to offer practical guidance (16). From empirical works, a study explored hospital resilience throughout the COVID-19 recovery in the Eastern Mediterranean Region, and the need for service continuity planning was highlighted as one of the hospital roles (23). Another paper conducted in the Eastern Mediterranean Region emphasized the necessity of preventive and proactive contingency planning and strengthening preparedness capacities for such planning (24). Moreover, a recent study of hospital resilience factors in China (22) mentioned a demand for adjustment and optimization of response plans during a pandemic. However, prior studies had some drawbacks in guiding effective future actions. There was no limitation on the type or size of the healthcare facilities covered in the studies, and they did not give enough attention to the pandemic responses, considering the extent to which BCPs had been prepared in reality.

Existing research shows a wide range of aspects regarding pandemic responses, including lessons learned from experience on hospital resilience to the pandemic (24–26). An existing qualitative literature review on healthcare professionals' adaptation to COVID-19 (13), focusing on clinical settings for physical conditions, identified themes including an intensified need for individual and team capacity to handle changes in working conditions, as well as shifts in healthcare organizations to address the challenges of the pandemic. While a qualitative study focused on outbreak management by frontline workers and leaders during the pandemic in long-term care in Canada (11), many others examined psychological burdens and challenges in this setting (27, 28). To the best of our knowledge, studies considering the components of hospital resilience in vulnerable settings, especially small and medium-sized private LTCHs, during the pandemic are scarce. How these LTCHs should have navigated hospital operations rapidly in the face of limited resources during COVID-19 remains unclear. To foster LTCHs' preparedness and organizational resilience, it is important to understand how LTCHs respond to disruptions, and continue providing quality care and functioning during such unexpected crises. Addressing these research gaps, this study uses mixed methods to investigate LTCHs' perceptions of and practical responses to upholding hospital business continuity during the pandemic, considering key elements related to hospital emergency response.

This study shows a range of pandemic responses among HCWs in LTCHs from a mixed perspective, considering both quantitative and qualitative data. This study applied qualitative data to gain more detailed information about responses in order to explain and complement the quantitative findings. This study can enhance our understanding of their circumstances and assess whether any components were left out in the responses.

Regarding BCP and response to the continuity of essential service, both quantitative and qualitative data indicate that in LTCHs, inpatient services were perceived as a critical function. However, they experienced some disruptions to rehabilitation services, which were deprioritized compared to other primary care services during the pandemic. Rehabilitation rooms were at risk of spreading the infection due to the need for direct patient contact and the high possibility of patients mixing together. The grounds for selecting operations in LTCHs were supported by qualitative data, which provided additional insights. Different from LTCHs in Korea, hospitals in Delhi (18) identified the emergency department as a critical function, as it is based on hospital type and specific circumstances. During the pandemic, a recent study showed that a hospital in Singapore identified orthopedic surgery as an essential service, reviewed and postponed non-urgent elective surgeries, and reduced outpatient visits to continue providing core musculoskeletal care (38). Further to this, during the pandemic, despite local differences in the choice of which specific services to maintain, hospitals prioritized essential services and canceled/postponed non-urgent care in countries in the WHO European region and Canada (39). In health service continuity planning as an ongoing and proactive process, identifying critical functions and recovery time objectives for each hospital based on its unique situation is necessary, and thus helps LTCHs reprioritize resources and efforts to continue their essential services (19, 40).

In addition, we found that many LTCHs quickly created BCPs using sample plans, but their operational status appeared to be unsatisfactory. The qualitative results, in which HCWs described their experiences of making action plans once they received their first confirmed case, help explain inefficient BCP implementation. The combined data showed that they may have experienced difficulties in building and implementing BCPs in situations with limited time and resources, including setting criteria for quarantine and essential services. While developing and testing BCPs tends to take several months, LTCHs in Korea had to create BCPs within just a few weeks for the first time because the government urged planning due to the pandemic. This has been criticized for mainly focusing on the reduction of isolation periods rather than properly reflecting the realities in each case (41, 42). Similarly, during the response to COVID-19, as their initial response, many countries focused on planning in hospitals; some countries determined the overall response, while others provided guidance, and left individual hospitals responsible for how they implemented the measures (39). Therefore, LTCHs should plan for a potential pandemic with a permanent BCP committee, taking the time to develop a BCP that covers all the critical components and periodically updating it (19, 20); in turn, their BCP would be effectively implemented during actual crises.

The WHO (33) emphasizes that well-functioning command-and-control systems are related to effective emergency management operations. In the quantitative data, LTCHs reported that response teams were mostly formed after the COVID-19 outbreak, but the operational effectiveness of most teams did not fall below average. Qualitative data provided further explanation of the response team's operation through workplace culture and leadership. Many HCWs reported that doctors who are owners/founders of hospitals were called directors/heads of the hospital. Due to this decision-making structure, implementation in an outbreak response can be made quickly without the approval of other parties. Global studies in the COVID-19 era corroborate that, because crisis management depends on hospital leadership, leaders should be trained to improve their inadequate leadership skills and serve as a champion (23, 43, 44). Consistent with our findings, a previous study (24) found that strong leadership with a clear vision can help push a hospital through the pandemic; the leadership of middle management also needs to be equipped to improve hospital outbreak response, since middle management is responsible for executing much of the day-day work (24). Moreover, during the pandemic, respectful organizational culture focusing on team-based approaches also fostered resilience for outbreak response, which is consistent with a previous study in long-term care (11). This implies that workplace culture and organizational leadership may hold a significant portion of the key continuity strategies and resources of private LTCHs.

In terms of communication, quantitative data showed that LTCHs reported a lack of smooth and effective risk communication between LTCHs and local health authorities. Meanwhile, qualitative data indicated that intra-hospital communication was relatively smooth when using smartphone technology, and sharing information with other LTCHs was beneficial for pandemic responses. The combined data highlighted a need to establish and activate a system with clear communication channels between authorities/stakeholders and LTCHs for real-time access, information exchange, and updates without delay or confusion. Some of these results echo the findings of a study that, through a multinational survey, pointed to increased use of virtual technologies for communication among health professionals, in parallel with changes during the pandemic, to keep staff connected and up to date with the ever-changing situation (45). Therefore, it is important to include information on communicating with stakeholders in BCP and provide support to address obstacles in order to ensure effective communication across and beyond hospitals during crises (40, 46).

Concerning the safety response, of the objectively measured new/intensified tasks, access control for safety accounted for the highest proportion. LTCHs reported implementing cohort isolation and experienced a high degree of difficulty in transferring patients during the process. The qualitative data confirmed these findings and revealed vulnerabilities and a process of trial and error in LTCHs. LTCHs in Korea lacked well-equipped isolation rooms and infection control specialists, so they had no choice but to follow the policy of transferring confirmed patients to hospitals dedicated to infectious diseases in the early phases, despite concerns over the quality of care in those hospitals (47). Later, a small number of designated hospitals with limited capacity were unable to admit confirmed patients, which led to transfer delays and the possibility of a surge in cluster infections in LTCHs (48). This is consistent with a study that found that several countries designated specific hospitals for the receiving and treatment of COVID-19 patients, but as case numbers increased, this arrangement was adapted, requiring other hospitals to admit confirmed cases as well (39). In addition to the lack of negative pressure isolation rooms, the lack of infection prevention and control (IPC) facilities, including single occupancy rooms for isolation, clear route separation, mandatory installation of ventilation systems, and a novel type of separate visiting area, further complicated the response to safety concerns (9, 49, 50). Taking this situation seriously, the government should provide financial and policy support to ensure the installation of IPC-related facilities, the activation of non-contact visits, and the proper layout of spaces in LTCHs, in preparation for future pandemics.

This study shows the pandemic placed a substantial burden on resource responses, pushing LTCHs to their limits, mirrored in other studies (11, 13, 20, 51). In particular, manpower issues throughout the pandemic response were frequently identified as the biggest challenge. The qualitative results in which HCWs described their experience of addressing human resources, largely confirmed and provided details on various self-help solutions. From this combined data, inferences emerged that pointed to desperate efforts to prevent staff shortages due to staff infections, as well as the impact of the pre-existing staffing issues of small and medium-sized LTCHs in Korea, including the absolute shortage of HCWs and instability in workforce quality, resulting in reduced care quality. Research involving hospitals in five countries (25) demonstrated comparable results; in terms of human resource management, during the pandemic, recruitment and retainment strategies were emphasized, including task-shifting with administrative staff assisting other services, recruitment of short-term contractors, moving staff within facilities, and simplifying recruitment, leading to hiring poorly qualified staff and less effective reinforcement in subsequent waves. This stresses the necessity for establishing a staff management and supervision system through collaboration between LTCHs and health authorities, including a human resources roster for infectious disease control and treatment, rather than counting on short-term solutions from individual LTCHs (25, 33). Considering the issues with care policies in Korea, improving the care worker system is also required, including the coverage of care worker costs through the National Health Insurance (48). Moreover, rewards for staff described during interviews, supporting and protecting staff can act as an important buffer against higher workload. Along with band-aid solutions for meeting immediate needs, better responses could be achieved through medium- to long-term strategies and planning, including needs assessment, ensuring an appropriate workload, and the development of incentive packages (52).

Quantitative results identified that in LTCHs, monitoring financial indicators was lacking in practice, and receiving compensation from the government was also difficult. Qualitative data provided more details insights into their limited financial responses. This meant that fiscally strained LTCHs, without a financial plan and plan evaluation, would not be able to provide adequate care to both infected patients and the remaining patients during the pandemic. The literature in this area stressed the need for increased fiscal autonomy for effective responses during the pandemic (24). Identifying funding sources as well as planning flexible contingency funds and reimbursement beforehand are foundations to meet additional demands for response (40). Also, additional financial compensation for hospitals' financial losses was a motive in other countries (53), so the government should develop payment systems to implement compensation for pandemic-related losses quickly, directly, and with great attention to distressed LTCHs.

How supply responses were made to address the continuity of the LTCHs' supply was provided by qualitative data. This may be related to the fact that the need of supplies was recognized without sufficient time to estimate or plan it in advance, consistent with previous research (47). Inconsistent assistance for PPE from the government and limited finances may also have an impact on supply management in LTCHs during the pandemic (28). This result aligns with earlier studies showing that tensions related to uncertainty about supplies were experienced due to a lack of diversity of supply channels, the absence of an inventory management tool, and shortages in the market, resulting in delivery delays and efforts to minimize unnecessary consumption and material waste, as well as efforts toward needs-based distribution (13, 24, 25). In this regard, evidence on hospital resilience has pointed to the importance of the government's proactive preparedness and comprehensive contingency planning, including the acquisition of supplies (23). Based on this lesson, it is important to plan for supply vulnerabilities at both the facility and national levels, including establishing a centralized supply system for the LTCHs through the health authority and alternative supply chains, maintaining reserves, and identifying storage space, to mitigate shortages of supplies (20).

Novel perspectives on LTCHs' BCP and responses to the pandemic in practice were gathered from HCWs, which contributes insights for developing and guiding preparedness plans and policies for vulnerable healthcare facilities in similar contexts, not only in Korea but also other countries, and provides evidence to enhance future responses. Similarly, studies suggest that small healthcare facilities should have BCPs to mitigate the impact of disasters, as damages (including preventable disaster death) occur in most hospitals with fewer beds, and patients cannot differentiate between the services available (18, 19, 54). It is thus imperative to be well prepared, including adaptive leadership, resilient staff, and established contingency funds for sustainable financing, regardless of hospital size (23, 55).

Nonetheless, its limitations should be acknowledged. First, our sample size was relatively small albeit focused on HCW representatives from LTCHs, restricting the conduct of additional inferential analyses. The low number of evaluated LTCHs in Korea also limits the generalizability of the results and findings; however, this indicates that this is an exploratory study, and further research is needed to gain a clearer understanding of responses in specific aspects and relevant factors in LTCHs. Moreover, this initial and exploratory study provides important information on this topic, but our study could be affected by the potential for selection bias. To obtain a representative sample for quantitative data, we attempted to recruit HCWs through professional associations/platforms used by small and medium-sized hospitals; however, recruitment was challenging during the pandemic, and self-selection bias cannot be prevented. While the selected small and medium-sized LTCHs are typical response cases in Korea, the interview participants may not represent the entirety of LTCHs. These may impact the generalizability and credibility of the findings. Future studies with more rigorous sampling methods, such as stratified random sampling, could be used to obtain more representative samples. Another limitation is related to the timing of data collection, which can lead to recall bias. In light of the persistence of the pandemic up to the Omicron period, HCWs were asked about their overall experiences while responding to the pandemic a few years after the initial outbreak. Additionally, a one-time survey of HCWs is limited in specifically capturing recovery phases and the changes across multiple waves of the COVID-19 pandemic, not the overall responses.

This study provides an opportunity to capture lessons learned by LTCHs that did not internalize BCPs when responding to crises. To protect vulnerable patients, ensuring the continuation of the LTCH operation is vital during a pandemic. The key lesson is that planning that fits the needs of the LTCHs and BCP implementation are critical to the LTCH's response and ultimately resilience. Considering BCP elements of planning within LTCHs is necessary to identify strong and weak points to prepare for and respond to future pandemics. To improve organizational resilience in LTCHs, there is a need for comprehensive continuity management strategies, including innovative platforms and policies, to support devising and implementing a realistic and effective contingency plan, and ensuring ongoing preparedness. At the same time, based on the findings, LTCHs need further adjustments and enhancements in their BCPs along with live, structured action plans, and should embed BCPs into the organization's culture.